Unusual case of acute abdomen: giant colonic diverticulum.

Non-steroidal anti-inflammatory drug-induced small bowel diaphragm disease Small bowel diaphragm disease is rarely seen in clinical practice and can pose a diagnostic dilemma.We present an interesting case of non-steroidal anti-inflammatory drug (NSAID) enteropathy following self-medication. A 42-year-old woman presented with history of colicky abdominal pain, anaemia and weight loss. She had taken ibuprofen (self-medication) t.d.s. for 7 months. Endoscopy, computed tomography (CT) of the abdomen and pelvis were normal. Barium studies on the small bowel were normal. A diagnostic laparoscopy showed an area of stricturing in distal small bowel. This was resected and histology showed NSAID-induced small bowel diaphragm. She was taken off ibuprofen and started on proton pump inhibitors. Unfortunately her symptoms returned after a year. It was found out that she continued to take NSAID over the counter. She underwent a mini laparotomy and 100 cm of proximal ileum with 30 diaphragms (strictures) was resected (Figs 1,2). Histology confirmed NSAID enteropathy. Non-steroidal anti-inflammatory drug uptake by enterocytes uncouples oxidative phosphorylation, mitochondrial damage and increased permeability. This exposes bowel wall to luminal contents and causes damage. The cytoprotective property of prostaglandins is also lost because of its inhibition. Systemic effects after absorption and recurrent local effects due to enterohepatic circulation have also been suggested, namely macroscopic is multiple circumferential strictures and microscopic is submucosal fibrosis similar to chronic ischaemia. Patients present with nausea, vomiting, diarrhoea, iron deficiency anaemia, pain, weight loss, hypoproteinaemia and obstruction. Investigations, such as endoscopy, barium studies, CT scan and laparoscopy can be useful but may yield false-negative results. Capsule enteroscopy is effective but may precipitate obstruction